Stesura Seveso 219Archivio Italiano di Urologia e Andrologia 2020; 92, 3 ORIGINAL PAPER No conflict of interest declared. DOI: 10.4081/aiua.2020.3.219 A global snapshot of endourology residency training Asad Ullah Aslam 1, 2, Joseph Philipraj 1,3, Sayed Jaffrey 1,4, Noor Buchholz 1 1 U-merge Ltd. (Urology for emerging countries), London, UK*; 2 Dept. of Urology, Letterkenny University Hospital, Saolta Healthcare Group, Ireland; 3 Department of Urology, Mahatma Ghandi Medical College & Research Institute, Sri Balaji Vidyapeeth, Pondicherry, India; 4 Dept. of Urology, University College Hospital, Galway Clinic and Bons Secours Hospital, Galway, Ireland. * U-merge Ltd. (Urology for Emerging Countries) is an academic urological platform dedicated to facilitate knowledge transfer in urology on all levels from developed to emerging countries. U-merge Ltd. is registered with the Companies House in London/ UK. www.U-merge.com Background: Urology has become more complex over the last decades with surgical sophisticated technologies such as endoscopy, laparoscopy and robotic surgery. As these minimally invasive methods gain popularity throughout the world, this has led in some countries to a serious training gap as compared to other countries, and between generations of surgeons within national training sys- tems. There is a huge heterogeneity in urological training between countries, whether developed or developing. This paper attempts to shed some light onto global urological train- ing, comparing a significant number of various national sys- tems, and to outline global tendencies in urological training. It will enable interested readers to see where their own system stands in international comparison, and hopefully enable them to identify training needs to achieve global quality standards. Materials & methods: This is a questionnaire-based assess- ment which was sent to 240 members of U-merge from 62 countries. In addition, there is ample literature on the require- ments of structured training programs and assessments, and we have tried to briefly outline the key points in this paper. Results: We received responses from 32 countries Urology res- idency training is hugely heterogenous between countries. Only 44% of nations use a structured training program with assessments. Others use the Halstedian apprenticeship approach. Notably, some developing countries do use modern teaching and assessment methods, whereas some developed countries still use the outmoded apprenticeship model. For the interested reader, results have been tabled in detail, and train- ing systems described country by country. Conclusions: Our results have shown a huge heterogeneity in quality urology training between countries and within conti- nents. In systems without national structure of training, it can be assumed that such differences exist even between hospitals/ training institutions. There is no doubt in times of globaliza- tion with resident and doctor migration and exchanges that training needs structure and standardization. The still huge gap in developing countries to catch up and be able to afford latest surgical and learning technologies need to be addressed with the help of responsible outreach programs. KEY WORDS: Surgical training; Urology; Endourology; Performance assessment; DOPS; Dry lab; Wet lab; Simulator training; Global education. Submitted 2 March 2020; Accepted 15 March 2020 Summary INTRODUCTION An estimated 5 billion people lack access to any surgical care. This despite surgical diseases accounting for 11- 30% of the global health care burden (1). This implies an urgent need to quality-train more surgeons in all spe- cialties globally. Historically, surgical training, and urological training as a surgical sub-specialty as well, followed the Halstedian tra- dition of defined apprenticeship. This includes basically observation, modelling and graded participation in surgi- cal activities. This model of training is characterized through long working hours, poorly defined training goals, and a lack of focus on research and evidence-based best practice. In this traditional system, assessment and evaluation of the trainees’ performance is outmoded, sig- nificantly subjective, with standards ill-defined and not uniformly applied (2). The optimal method to monitor and assess trainees, for example in endoscopy, has not been formally determined (3). Urology has become more complex over the last decades with increasing medical and surgical sophisticated technologies such as endoscopy, laparoscopy and robotic surgery. As these minimally inva- sive methods gain popularity throughout the world, this has led in some countries to a serious training gap as com- pared to other countries (4), and between generations of surgeons within national training systems. There is a huge heterogeneity in urological training between countries, whether developed or developing (5, 6). Most countries have a urological training duration of around 5 years, but this may include rotations in nephrology, pediatric sur- gery, gynecology, general surgery, anesthesia, pathology and others (4). Numerous recent studies have shown that trainees remain dissatisfied with their training in urology in many countries (7-12). The educational landscape in urology training is changing and adapting to modern learning methods. Globalization of demands and services also means there clearly is a need for a standardized and structured urological training for global use. This must also include competency-based assessment, cer- tification and re-certification (3). Naturally, these changes are adopted by various countries in various ways and speeds. This has led at the current time to a wide variation of training quality between countries and training systems. U-merge is a urological educational platform. Its members are active in international teaching & training in many countries globally. Therefore, the authors have seen first- hand huge differences in structures and quality of urolog- ical training programs. Programs may vary from the old- Archivio Italiano di Urologia e Andrologia 2020; 92, 3 A. Ullah Aslam, J. Philipraj, S. Jaffrey, N. Buchholz 220 fashioned apprenticeship model with a see one, do one, teach one approach, to highly structured, sometimes nationalized training programs using modern technologies such as virtual, simulated and telemedical training. This paper attempts to shed some light onto global uro- logical training, comparing a significant number of vari- ous national systems, and to outline global tendencies in urological training. We focus on endourology and pedi- atric endourology training as representative for recent technological changes in urology. This paper will enable interested readers to see where their own system stands in international comparison, and hopefully enable them to identify training needs to achieve global quality standards. MATERIALS AND METHODS This paper is based on a questionnaire which was sent in 2015 to 240 members of U-merge from 62 countries (Appendix 1). U-merge members are consultant level academic urologists in their respective countries. The questionnaire addressed • Structure and duration of the urology training program • Training in basic urology and endourology (if any) • Sub-specialty training in pediatric urology • Assessment structure • Availability of simulated training options. No funding has been obtained to conduct this study. RESULTS Cumulative results Of 240 questionnaires emailed to U-merge members in 60 countries, we received 37 (15.4%) responses from 32 countries. Twenty-one (56%) of these have no structured training program. Urology training follows an apprentice- ship model. The other 16 have a structured training pro- gram. Endourology training can be integrated into the mainstream residency training or have its own defined training period. Duration of training within structured programs varies from 0.5 to 6 years. In 7 (18%) countries, urology residency training can be completed without gain- ing competency in endourology. 8 (21%) do not require URS, 17 (46%) do not require fURS/RIRS, and 18 (48%) do not require PCNL competency. 3 (8%) countries require endourology training in children (Table 1). As per specific endourological procedures, 22 (59%) of countries require their trainees to be independently com- petent in URS, 5 (13%) to be competent with assistance, and 2 (5%) require mere exposure during training. In 10 (27%) URS training has not been specified. For fURS/RIRS, the numbers are 9 (24%), 10 (27%), 6 (16%), and 13 (35%), respectively. For PCNL the num- bers are 6 (16%), 13 (35%), 9 (24%), and 12 (32%), respectively. For endourological procedures in children, independent competency is usually not required to com- plete urology residency. 4 (11%) of countries require Table 1. Structured urology training programs and endourology components by country. Country Structured Duration endourology Completion of training Completion of training Completion of training Completion of training Completion of training endourology training program without competence without competence without competence without competence without competence training (years) in endouro procedures in URS in fURS/RIRS in PCNL in EndoUro in Children Algeria No Not applicable Yes No No No Yes Austria No Not applicable Yes No No No Yes Australia Yes 6 Yes No No No Yes Bangladesh No Not applicable Yes Yes Yes Yes Yes Brazil Yes 0,5 Yes No Yes No Yes Bulgaria Yes 1 Yes No No No Yes Canada No Not applicable Yes No No Yes Yes China No Not applicable Yes No No Yes Yes Colombia No Not applicable Yes No Yes Yes Yes Egypt No Not applicable Yes No Yes No Yes El Salvador No Not applicable Yes Yes Yes Yes Yes France No Not applicable No No No No Yes Germany Yes 5 Yes No Yes Yes Yes Greece No Not applicable Yes No Yes Yes Yes India Yes 5 Yes No Yes Yes Yes Iran Yes 2 Yes No Yes Yes Yes Iraq Yes 3 Yes Yes Yes Yes Yes Ireland Yes 6 No No No No Yes 1Italy no Not applicable Yes Yes Yes Yes Yes Kenya Yes 4 Yes No No No Yes Kurdistan Yes 1 No No No No Yes Moldova No Not applicable Yes No Yes Yes Yes Morocco Yes 5 Yes Yes Yes Yes Yes Nepal Yes 3 No No No No No Oman No Not applicable Yes Yes Yes Yes Yes Pakistan Yes 6 Yes No No No Yes Panama No Not applicable Yes No No No Yes Romania No Not applicable Yes No No No Yes Serbia No Not applicable Yes No No Yes Yes South Africa No Not applicable No No No No No Spain No Not applicable Yes Yes Yes Yes Yes Sweden Yes 5 Yes No No No Yes Syria No Not applicable Yes No Yes Yes Yes Tunisia Yes 2 No No No No No UAE No Not applicable Yes Yes Yes Yes Yes UK Yes 5 No No No No Yes Ukraine No Not applicable Yes No No No Yes competency with assistance by trainers, and 3 (8%) require some exposure during training. Some countries offer post-residency training on a fellowship level: 3 (8%) for fURS/RIRS, 6 (16%) for PCNL, and 6 (16%) for pediatric procedures, respectively (Table 2). Twenty-one (56%) countries have defined a minimum procedure number for endourology training: 20 (54%) for URS, 13 (35%) for fURS/RIRS, 18 (48%) for PCNL, and 7 (19%) for pediatric endourological procedures. Indicative num- bers vary widely: 10-450 for URS, 10-100 for fURS/RIRS, 6-250 for PCNL, and 2-300 for pediatric procedures, respectively (Table 3). Twenty-six (70%) countries have no structured performance assessment during training in place. 19 (51%) rely on a general assessment, 12 (32%) perform regular audit, 9 (24%) use examinations as a tool of assessment, and 14 (38%) apply formal Direct Observation of Procedural Skills (DOPS) (Table 4). Regarding simulated surgical skills training, 7 (19%) have a “dry lab” facility for URS at their disposal, anoth- er 7 (19%) have a “wet lab” training option for URS. 6 (16%) have these as a compulsory training part in their programs. Each 6 (16%) countries offer either for fURS/ RIRS training, and 6 (16%) offer “dry lab” and 5 (13%) “wet lab” training for PCNL. Each 3 (8%) use these as compulsory part of training (Table 5). Results by country As mentioned before, twenty-one (56%) countries have no structured training program (Figure 1). Urology training follows an apprenticeship model. Another 16 have a struc- tured training program of varying duration and perform- ance assessments (Figure 2). In the following we present a short summary for the urological training in all responder countries in alphabetical order. The following 21 countries have NO structured training program: 1. Algeria The completion of urological training includes competence in URS (semi-rigid ureteroscopy), fURS/RIRS (flexible ureteroscopy/retrograde intrarenal surgery) and PCNL (percutaneous nephrolithotomy), with exception of endourological procedures in children. Trainees are expected to perform a minimum of 10 cases each of URS and fURS/RIRS. In addition, fifteen PCNL with trainer assistance is a requirement. There is compulsory wet lab training on animal models for URS, fURS/RIRS and PCNL. No structured method of performance assessment has been specified. 2. Austria For endourological procedures (URS, fURS/RIRS, PCNL) a combined minimum case load of 150 procedures is required. There is no specified level of competence for these endourologal procedures in children. There is no 221Archivio Italiano di Urologia e Andrologia 2020; 92, 3 Global urology training Table 2. Core competencies required in endourology by country. Country URS Perform URS perform URS URS Lwarn URS not fURS/RIRS fURS/RIRS fURS/RIRS fURS/RIRS fURS/RIRS PCNL PCNL perform PCNL PCNL Learn PCNL not Endourol in Endourol in Endourol in Endourol in Endourol in independently with exposure at specialist specified Perform perform with exposure Learn at not specified Perform with exposure at specialist specified children children children children Learn children assistance fellowship level independently assistance specialist independently assistance fellowship level Perform perform with exposure at specialist not specified fellowship level independently assistance fellowship level Algeria Yes Yes Yes Yes Yes Austria Yes Yes Yes Yes Australia Yes Yes Yes Yes Bangladesh Yes Yes Yes Yes Brazil Yes Yes Yes Yes Bulgaria Yes Yes Yes Yes Canada Yes Yes Yes Yes Yes Yes Yes China Yes Yes Yes Yes Colombia Yes Yes Yes Yes Egypt Yes Yes Yes Yes El Salvador Yes Yes Yes Yes France Yes Yes Yes Yes Germany Yes Yes Yes Yes Greece Yes Yes Yes Yes India Yes Yes Yes Yes Iran Yes Yes Yes Yes Iraq Yes Yes Yes Yes Yes Yes Yes Yes Yes Ireland Yes Yes Yes Yes Italy Yes Yes Yes Yes Kenya Yes Yes Yes Yes Yes Yes Kurdistan Yes Yes Yes Yes Moldova Yes Yes Yes yes Morocco Yes Yes Yes Yes Nepal Yes Yes Yes Yes Yes Yes Yes Oman Pakistan Yes Yes Yes Yes Panama Yes Yes Yes Yes Romania Yes Yes Yes Yes Serbia Yes Yes South Africa Yes Yes Yes Yes Spain Yes Yes Yes Yes Sweden Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Syria Yes Yes Yes Yes Tunisia Yes Yes Yes Yes UAE Yes Yes Yes Yes UK Yes Yes Yes Yes Ukraine Yes Yes Yes Yes Archivio Italiano di Urologia e Andrologia 2020; 92, 3 A. Ullah Aslam, J. Philipraj, S. Jaffrey, N. Buchholz 222 Table 3. Minimum endourology procedure numbers required by country. Country Min No. URS Min URS indicative fURS/RIRS min no. fURS/RIRS PCNL min no. PCNL indicative Endourology in chilidren Endourology in children All 4 procedures Not of case load No. of Case Load number of caseload indicative numbers of caseload numbers min no. of caseload indicative numbers combined case numbers specified Algeria Yes Yes 10 Yes 10 Yes 15 No 0 Not mentioned Austria Yes Yes Not mentioned Yes Not mentioned Yes Not mentioned Yes Not mentioned 150 Australia Yes Yes 100 Yes 75 Yes 15 No 0 Not mentioned Bangladesh No No 0 No 0 No 0 No 0 No Brazil Yes Yes 12 No No Yes 6 No No Bulgaria Yes Yes 50 Yes 10 Yes 10 No No Not mentioned Canada No No Not mentioned No Not mentioned No Not mentioned No Not mentioned Not mentioned China No No Not mentioned No Not mentioned No Not mentioned No Not mentioned Not mentioned Colombia No No No No No Not mentioned Egypt Yes Yes 60 Yes 20 Yes 30 Yes 10 Not mentioned El Salvador No No No No No No No No No Not mentioned France No Yes 50 Yes 50 Yes 20 No No Not mentioned Germany No Yes 50 No No No No No No Not mentioned Greece No No No No No No No No No Not mentioned India Yes Yes 20 Yes 20 Yes 5 Yes 2 Not mentioned Iran Yes Yes 70 No No Yes 50 Yes 10 Not mentioned Iraq Yes Yes 450 Yes 30 Yes 60 Yes 300 Not mentioned Ireland Yes Yes 50 Yes 50 Yes 10 No No Not mentioned Italy no No Yes Kenya Yes Yes 50 Yes 50 Yes 30 No No Not mentioned Kurdistan Yes Yes 200 Yes 100 Yes 250 Yes 20 Not mentioned Moldova No No Yes Morocco No No No No No No No No No Not mentioned Nepal Yes Yes 200 Yes 25 Yes 100 No Not mentioned Not mentioned Oman Yes Pakistan Yes Yes 400 No No Yes 250 No No Not mentioned Panama No Yes Romania Yes Yes 20 No No Yes 20 No No Not mentioned Serbia Yes Yes 50 No No No No No No Not mentioned South Africa No No No No No No No No No Not mentioned Spain No No No No No No No No No Not mentioned Sweden No No No No No No No No No Not mentioned Syria No No No No No No No No No Not mentioned Tunisia Yes Yes Not mentioned No No Yes 20 No No Not mentioned UAE No No Yes UK Yes Yes 50 Yes 50 Yes 10 Yes 10 Not mentioned Ukraine No No No No No No No No No Not mentioned Country General assessment of performance Audit Formal examination/viva Direct Obs of Procedure Skills (DOPS) Several of above assessments No specific assessment Algeria No No No No No Yes Austria Yes Yes Yes No Yes No Australia Yes Yes Yes Yes Yes No Bangladesh No No No No No Yes Brazil No No No No No Yes Bulgaria Not mentioned Not mentioned Not mentioned Not mentioned Yes No Canada Not mentioned Not mentioned Not mentioned Not mentioned Yes No China No Yes No Yes Yes Yes Colombia Not mentioned Not mentioned Not mentioned Not mentioned Yes Yes Egypt Yes No Yes Yes Yes Yes El Salvador No No No No No No France Yes Yes Yes Yes Yes Yes Germany No No No No No No Greece Yes No No Yes Yes Yes India Yes No No No No Yes Iran Yes Yes No Yes Yes Yes Iraq Yes Yes Yes Yes Yes Yes Ireland Yes Yes No Yes Yes Yes Italy Kenya Yes Yes Yes Yes Yes Yes Kurdistan Yes Yes No Yes Yes Yes Moldova No No No No No No Morocco Yes No No No No Yes Nepal Yes Yes Yes No Yes Yes Oman No Pakistan Yes Yes Yes No Yes Yes Panama No No No No No No Romania No No No No No No Serbia Yes No No No No Yes South Africa Yes No No Yes Yes Yes Spain No No No No No No Sweden No No No Yes No Yes Syria Not mentioned Not mentioned Not mentioned Not mentioned Yes Yes Tunisia Yes Yes No Yes Yes Yes UAE UK Yes No Yes Yes Yes Yes Ukraine Yes No No No No Yes Table 4. Performance assessments by country. 223Archivio Italiano di Urologia e Andrologia 2020; 92, 3 Global urology training compulsory dry or wet lab training. The assessment is via general assessment of performance, audit and formal examination with viva by the trainers. 3. Bangladesh Trainees can achieve completion of training without proven competence in fURS/RIRS, PCNL and endouro- logical surgery in children. They are required to perform some URS and PCNL with trainer assistance. Endourology in children is later taught at fellowship level. Indicative numbers of procedure and performance assessment methods are not specified. 4. Canada URS and fURS/RIRS are a requirement for completion of training with candidates expected to perform these pro- cedures independently. Endourology in children and PCNL is taught at fellowship level post-residency. Model training is not compulsory. Various method of assess- ment of performance are in place. 5. China For completion of training, URS with trainer assistance is required. However, trainees are expected to have had exposure to fURS and PCNL. There is no specified endourology training in children. There is dry lab training for URS and wet lab training for fURS and PCNL, albeit not compulsory. Audit and DOPS are used for assessment. 6. Colombia URS is mandatory and trainees are expected to perform it independently. fURS and PCNL with trainer assistance are required. Endourology in children is not regulated. There is no model training and no specific assessment structure in place. 7. Egypt Trainees can complete their training without gaining inde- pendent level competence in fURS/RIRS and endourologi- cal procedures in children. Twenty and 10 assisted or observed cases in fURS and paediatric endourology, respectively, are indicative, albeit not mandatory. URS and PCNL procedures are compulsory for the trainee to per- form independently, with indicative numbers of 60 and 30, respectively. There is no compulsory model training. Assessment of performance is via formal examination with viva and DOPS. 8. El Salvador There is no specified mandatory requirement for any endourological procedures. Indicative numbers, provision of model training, or assessment methods are not specified. 9. France There is no structured endourology training program. However, it is mandatory to achieve competence in URS, fURS/RIRS and PCNL. Endourological procedures in chil- dren is not a mandatory requirement. Fifty cases each for URS and fURS/RIRS, and 20 cases of PCNL are indicative, with numbers unspecified for paediatric endourology. There are dry and wet labs for each of these procedures. However, model training is not compulsory. Country URS DryLab URS WetLab URS Compulsory FURS DryLab FURS WetLab FURS Compulsory PCNL DryLab FURS WetLab FURS Compulsory Algeria No Yes Yes No Yes Yes No Yes Yes Austria No No No No No No No No No Australia No No No No No No No No No Bangladesh No No No No No No No No No Brazil NS NS No NS NS No NS NS No Bulgaria Yes No Yes Yes No Yes Yes No No Canada No No No No No No No No No China Yes No No Yes Yes No Yes Yes No Colombia No No No No No No No No No Egypt No No No No No No No No No El Salvador No No No No No No No No No France Yes Yes No Yes Yes No Yes Yes No Germany No Yes Yes No No No No No No Greece No No No No No No No No No India Yes No No Yes No No Yes No No Iran No No No No No No No No No Iraq No Yes Yes No Yes Yes No Yes Yes Ireland No No No No No No No No No Italy No No No No No No No No No Kenya No No No Kurdistan No No No Moldova No Yes Yes No No No No No No Morocco No No No Nepal No No No No No No No No No Oman no info Pakistan No No No Panama No No No Romania No No No Serbia Yes Yes No Yes Yes No Yes Yes No South Africa No No No No No No No No No Spain No No No No No No No No No Sweden Yes Yes No Yes Yes No No No No Syria No No No No No No No No No Tunisia Yes No Yes No Yes No Yes No Yes UAE no info UK No No No No No No No No No Ukraine No No No No No No No No No Table 5. Availability and integration of dry & wet lab model training into the training program by country. Archivio Italiano di Urologia e Andrologia 2020; 92, 3 A. Ullah Aslam, J. Philipraj, S. Jaffrey, N. Buchholz 224 Figure 1. Countries with no structured (endourology) training and indicative numbers of procedures (empty bars indicate no minimum number specified). Figure 2. ountries with structured (endourology) training programs: duration of training. 225Archivio Italiano di Urologia e Andrologia 2020; 92, 3 Global urology training Assessment of performance is via several methods includ- ing audit, general assessment, formal examination and viva with DOPS. 10. Greece URS is a mandatory requirement with no specified indica- tive numbers. Completion of training is possible without further competence in endourology. There is no provision of model training. Assessment of per- formance is via general assessment and DOPS. 11. Italy There are no competence requirements for endourology. Indicative numbers are unspecified. There is no provision of model training. Assessment methods are not specified. 12. Moldova Trainees are expected to gain independent level compe- tence in URS for completion of training with unspecified indicative numbers. There is compulsory URS wet lab on animal models. The performance assessment method is unspecified. 13. Oman Endourology is not a mandatory requirement for com- pletion of training. There are no specified indicative numbers, model training or assessment methods. 14. Panama URS, fURS/RIRS and PCNL are mandatory requirements for completion of training, however indicative numbers are not specified. Dry and wet labs are not available, and there is no specified method of assessment. 15. Romania Although there is lack of structured endourology train- ing, for completion of training it is mandatory to achieve competence in URS, fURS/RIRS and PCNL. URS and PCNL are expected to be performed independ- ently, fURS with trainer assistance. Twenty cases for URS are indicative. Dry and wet labs are not compulsory, and assessment of competency is not specified. 16. Serbia URS and fURS/RIRS are mandatory requirements to complete training with 50 cases for URS as indicative number. Dry and wet labs for each of these procedures are accessible by trainees, but not compulsory. Competency is assessed by general assessment. 17. South Africa It is mandatory to achieve competence in endourology for completion of training. Trainees are required to gain competence in all procedures (URS, fURS/RIRS, PCNL and paediatric endourology). Level of competence is not specified with no indicative numbers. There are no dry or wet labs. Assessment of performance is via general assessment and DOPS. 18. Spain Trainees are not required to gain competence in endourol- ogy to complete training. There are no specified indicative numbers, lab provisions or assessment methods. 19. Syria Trainees are required to gain independent level compe- tence in URS with exposure to PCNL and assistance in paediatric endourology. fURS training is not specified. There are no minimum case numbers and model train- ing. Assessment of performance is not specified. 20. United Arab Emirates There is no specific training program. 21. Ukraine URS, fURS/RIRS and PCNL are mandatory for comple- tion of training, however core competency, indicative numbers and lab provision are not specified. There is a general assessment of competency. The following 16 countries do have a structured training program (Figure 3): 1. Australia The training program runs for 6 years. It is mandatory to achieve competence in endourology for completion of training such as independent level competence in URS and fURS/RIRS. Performance of PCNL with assistance is a requirement. Paediatric endourology is learned at fel- lowship level. Indicative numbers include 100 URS, 75 fURS/RIRS, and 15 PCNL with no specified numbers for paediatric endourology. Dry and wet labs are not provi- sioned. Assessment of performance is via several meth- ods including audit, general assessment, formal exami- nation and viva with DOPS. 2. Brazil A 6 month endourology program is in existence with mandatory expertise in URS. PCNL with assistance and exposure to fURS/RIRS is deemed satisfactory. Twelve URS and 6 PCNL are indicative for completion of train- ing. There are no specified numbers for paediatric endourology. Lab training is not provisioned and there is no specified method of assessment of competence. 3. Bulgaria An endourology program of 1-year duration exists with trainees expected to perform URS independently and PCNL with assistance. Exposure to fURS/RIRS is manda- tory. Paediatric endourology is learned at fellowship level. Indicative numbers for each of these procedures are 50 URS, 10 each fURS/RIRS and PCNL. A dry lab is compulsory for each category, with the exception of endourology in children. Assessment of performance is via several methods including audit, general assessment, formal examination and viva with DOPS. 4. Germany A 5-year urology training program is in place. Endourology training comprises of mandatory URS. fURS/RIRS, PCNL and endourology in children is not specified. Fifty URS procedures are indicative. Wet lab for URS is compulsory. Assessment of performance is via several methods. 5. India Expertise in URS is mandatory as part of a 5-year uro- Archivio Italiano di Urologia e Andrologia 2020; 92, 3 A. Ullah Aslam, J. Philipraj, S. Jaffrey, N. Buchholz 226 logical training program. fURS/RIRS and PCNL are accepted to be performed with assistance. Paediatric endourology is not specified. Indicative numbers include 20 for URS, 20 for fURS/RIRS, 5 for PCNL and 2 in pae- diatric endourology. There is a provision of dry lab for each of these proce- dures, albeit not compulsory. Assessment of perform- ance is via general assessment. 6. Iran An endourology program runs for 2 years with inde- pendent expertise in URS being mandatory. PCNL and paediatric endourology exposure is necessary, whereas fURS/RIRS is not specified. Seventy URS, 50 PCNL and 10 paediatric endourology cases are indicative. There is no provision of dry and wet labs. Assessment of per- formance is via several methods including audit, general assessment and DOPS. 7. Iraq Endourology training for 3 years is mandatory, however trainees can finish training without gaining independent level competence in either of the endourology proce- dures with exception being URS. A minimum of 450 cases of URS, 30 of fURS/RIRS, 60 of PCNL and 300 of paediatric endourology are indicative. There is provision of dry and wet labs for each of these procedures which are compulsory. Assessment of performance is via sever- al methods including audit, general assessment, formal examination and viva with DOPS. 8. Ireland A 6-year training program exists, with a structured endourology training. URS, fURS/RIRS and PCNL are mandatory, with paediatric endourology learned at fel- lowship level. Trainees are required to gain independent level competence in URS and fURS/RIRS, with PCNL Figure 3. Countries with structured endourology training and indicative numbers of procedures required (empty bars indicate no number specified). 227Archivio Italiano di Urologia e Andrologia 2020; 92, 3 Global urology training performed with trainer assistance. Indicative numbers 50 URS, 50 fURS, and 10 PCNL. There is no provision of lab training. Assessment of performance is via several methods including audit, general assessment, formal examination and viva with DOPS. 9. Kenya URS, fURS/RIRS and PCNL are mandatory to achieve competence in endourology for completion of a 4-year training program. Paediatric endourology is performed at fellowship level hence not a requirement for comple- tion of training. Trainees are expected to perform URS and fURS/RIRS independently, and PCNL with assis- tance. Fifty cases each for URS and fURS/RIRS, and 30 cases of PCNL are indicative. Lab is not provisioned. Assessment of performance is via several methods including audit, general assessment, formal examination and viva with DOPS. 10. Kurdistan A one-year structured endourology training program makes it mandatory for trainees to be independently pro- ficient to perform URS and fURS/RIRS, and PCNL to be performed with assistance. There is no specified paedi- atric endourology training. Two hundred cases for URS, 100 for fURS/RIRS, 250 cases of PCNL, and 20 paedi- atric endourology cases are indicative. There is no provi- sion of lab training. Several methods such as general assessment, audit and DOPS are used for assessment. 11. Morocco The training program comprises endourology training and runs for 5 years. Trainees are required to gain expo- sure to URS, fURS/RIRS and PCNL in order to complete their training. Endourological procedures in children are not a mandatory requirement. There are no specified indicative numbers, and no lab training. General assess- ment of performance exists to assess competency. 12. Nepal It is mandatory to achieve competence in endourology for completion of training of a 3-year training. Trainees are required to gain independent level competence in URS, with fURS/RIRS and PCNL to be performed with trainer assistance. Endourological procedures in children are not a mandatory requirement. Two hundred cases for URS, 25 for fURS/RIRS, and 100 cases of PCNL are indicative, with no particularly specified numbers for paediatric endourology. There is no provision of lab training. Audit, general assessment, formal examination and viva are in place to assess competency of training. 13. Pakistan A 5-year program exists with mandatory endourology training. Trainees are required to gain independent level competence in URS, with fURS/RIRS and PCNL per- formed with trainer assistance. Endourological procedures in children are not a mandatory requirement. Four hun- dred cases for URS and 250 cases of PCNL are indicative, with no particularly specified numbers for fURS/RIRS and paediatric endourology. There is no provision of dry and wet labs for each of these procedures. Several methods exist including audit, general assessment, formal examina- tion and viva to assess competency. 14. Sweden It is a mandatory requirement to achieve competence in endourology for completion of a 5-year training pro- gram. Trainees are required to gain independent level competence in URS, fURS/RIRS and PCNL in order to complete their training. Endourological procedures in children and indicative numbers are not specified. There are dry and wet labs for URS and fURS/RIRS, which are however not compulsory. Assessment is via DOPS. 15. Tunisia A 2-year training program exists comprising of endourol- ogy training in URS and fURS/RIRS. PCNL is learned at fellowship level. Paediatric endourology is not specified. Trainees are required to gain independent level compe- tence in URS. Twenty PCNL performed with assistance are indicative. A compulsory dry lab for URS and PCNL exists with optional fURS wet lab. Assessment is via audit, general assessment, formal examination and DOPS. 16. United Kingdom The UK training program runs for 5 years with manda- tory competence in URS, fURS/RIRS and PCNL. Endourological procedures in children are not a manda- tory requirement. Trainees are required to perform URS and fURS/RIRS independently, with PCNL exposure, and no specified paediatric endourology. Fifty cases each for URS and fURS/RIRS, and 10 cases of PCNL, as well as 10 cases of paediatric endourology as indicative. There is no compulsory lab training. Competency assess- ment is via several methods including audit, general assessment, formal examination, viva and DOPS. DISCUSSION Our results have shown that there is a huge heterogene- ity between training systems in various countries. This has previously been confirmed by others (5,6). Urological training, although embracing modern learn- ing technologies in many countries, is far from ideal in most places. Inevitably, that will lead to huge differences in the training quality as well. In Europe, there is a general lack of standardized train- ing curricula. Great differences exist between training requirements in different countries. Trainees complain about a lack of confidence when performing major sur- gical procedures, non-compliance with European work- ing hour regulations, a worrisome risk of burn-out and a negative impact on their work-life balance (6). Irish res- idents complain mainly about a lack of operative experi- ence (7). In Spain, trainees find their training inadequate because of a lack of supervision, trainers completing their own training needs first, and a lack of operative experience (10). In Germany, 45% of trainees feel unpre- pared for their future roles. 85% complain about a lack in structured training, evaluations, and transparency. Another complaint is economic constraints during train- ing (8). Throughout South America, training, accredita- tion and re-certification are highly heterogenous and far Archivio Italiano di Urologia e Andrologia 2020; 92, 3 A. Ullah Aslam, J. Philipraj, S. Jaffrey, N. Buchholz 228 from being standardized. In addition, academic activities are not properly valued (5). Turkish residents report a lack of surgical exposure, and of encouragement for any academic activities (11). In Tunisia, most trainees in urology were dissatisfied with their training (9). Training is further compromised by reduced working hours for training as well as an increasing threat of liti- gation (12). All these studies confirm that there is a dire need to improve training quality in urology internationally. Not only may patient safety be compromised, but even the trainees themselves will face a future that they do not feel ready for, and that they are not adequately trained for. So how could one achieve a meaningful improvement? It appears that a well-structured training approach is key to ensure a surgeon’s professional growth in the safest way for the patients (4). Structured training is in place in some countries who may serve as a model for others. Structuring the training may start with the right candidate selection. A surgeon needs compassion, communication skills, and should be perceptive and dedicated, besides manually skilled (2). Structuring this crucial initial step of training, recruit- ment should be at least regional, if not national. Candidates must undergo a validated assessment by objective, well-trained and experienced assessors. The process should be overseen by national authorities such as colleges or deaneries. This way each candidate will have the same chances and will undergo the same assess- ment, decreasing the chance of subjective bias. The UK system may serve here as an example (13). The next step to structure would be the training program itself. Most modern training programs have already moved from a “see one, do one, teach one” approach to a structured learning – at least in minimally invasive treat- ment options –, and from e-learning to skills labs and modulated training settings (14). A structured training program will encompass a better definition of training goals and skills, specialization, structured evaluation, standardization of exams and include research (8). Simulation-based training can indeed address many con- cerns of the old apprenticeship model, such as patient safety, efficient acquisition of complex surgical skills, overcoming the learning curve, and cost-effectiveness (4, 15). Improved structured training should include struc- tured scheduling of activities, use of peer training, e- learning, access to simulation training on high fidelity models and/ or animals, trainee information on all avail- able resources, effective tutoring, research, and evidence based practice learning (2, 9, 16,17). A consensus has been reached on markers defining the quality of a surgical training program (18): - Trainer – trainee relationship - Operative exposure - Supervision - Feed back - Structures and organization of training - Structured teaching programs No training is effective without assessment of the com- petency and proficiency achieved by the trainee. However, assessments are often perceived as haphazard, subjective and non-transparent (5, 8). In structured simulation training programs, the most commonly used tools for objective assessment are (15): - Technical skills assessment - global rating scale of performance rating scores - questionnaires and post-training surveys - structured assessment by use of video recording - motion tracking software. Another established, effective and valuable tool in surgi- cal training assessment is the Direct Observation of Procedural Skills (DOPS) (19, 20). In any case, trainee assessment has to move away from the mere measure of the number of surgical procedures to mediation of competencies and skills as markers of competency (21, 22). A consensus statement has been reached on the quality markers of training assessment (18): - trainee feedback - trainer feedback - timetable structure - trainee improvement. However, there are also barriers to effective training assessment which we must bear in mind. These are uncer- tainty on what to document, concern of a negative impact on faculty popularity amongst trainees, lack of clear stan- dards, and lack of effective remediation options (23) According with the mission of Urology for emerging coun- tries (U-merge), the authors looked at a wide array of urological training in various countries. It is notable that structured training programs do not only exist in devel- oped countries, and old-fashioned apprenticeship mod- els do still prevail in some developed countries although modern learning options are readily available there, albeit not implemented. Especially but not only in the developing world, urolog- ical training is marred by inconsistency, lack of struc- ture, and lack of focus on research and evidence-based practice (2). This is where an international and/or global training approach comes into play. More affluent coun- tries could afford to help less fortunate countries to establish sustainable, capacity-building educational col- laborations that are essential to address the global bur- den of global disease. International collaboration can lead the way towards competency-based training, assess- ment of technical skills by international standards, long- term trainer proficiency, and community-specific quality initiatives (24). Established tools for this purpose are an online curriculum, visiting educator trips, expert sur- geon involvement, trainee competency tracking and identification of local outreach partners (25). However, any collaboration towards standardized and structured training needs to be responsible, meaning responding to locally identified needs, training projects according to local contexts, and a general working towards self-sufficiency of the trainees (26). Our results have shown a huge heterogeneity in quality urology training between countries and within conti- nents. In systems without national structure of training it 229Archivio Italiano di Urologia e Andrologia 2020; 92, 3 Global urology training can be assumed that such differences exist even between hospitals/training institutions. There is no doubt in times of globalization with resident and doctor migration and exchanges that training needs structure and standardiza- tion. 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Correspondence Asad Ullah Aslam, MD asadullahaslam@gmail.com Dept. of Urology, Letterkenny University Hospital, Saolta Healthcare Group (Ireland) Joseph Philipraj, MD josephphilipraj@gmail.com Department of Urology, Mahatma Ghandi Medical College & Research Institute Sri Balaji Vidyapeeth, Pondicherry (India) Sayed Jaffrey, MD jaffry@urology.ie Dept. of Urology, University College Hospital, Galway Clinic and Bons Secours Hospital, Galway (Ireland) Noor Buchholz, MD (Corresponding Author) scientific-office@u-merge.com U-merge scientific office Athens/Greece